Prior Authorization Clinical Specialist – Us Registered Nurse

The Prior Authorization Clinical Specialist – US RN is responsible for providing clinical expertise and operational support in the prior authorization and utilization management process for U.S. healthcare payers. This role ensures medical necessity determinations are accurate, compliant, and timely by applying clinical judgment, payer policies, and evidence-based guidelines. The US RN serves as a key escalation point for complex authorization cases, supports appeals, and partners with internal teams and external payers to optimize authorization outcomes while maintaining regulatory compliance.

Key Responsibilities:

Prior Authorization & Utilization Review

• Conduct clinical reviews for prior authorization requests involving medical procedures, services, and medications.
• Evaluate medical necessity using payer policies, evidence-based guidelines, and clinical judgment.

Clinical Review & Documentation

• Review medical records, physician notes, diagnostic results, and treatment plans to validate completeness and clinical appropriateness.
• Ensure accurate clinical documentation is submitted to support authorization and appeal requests.
• Identify documentation gaps and collaborate with providers or internal teams to obtain required clinical information.

Escalations & Appeals Management

• Serve as an escalation resource for complex, high-risk, or denied authorization cases.
• Support appeal preparation by providing clinical rationale, summaries, and supporting documentation.
• Collaborate with medical directors, providers, and payer clinical reviewers to resolve authorization barriers.

Policy Interpretation & Guidance

• Interpret payer medical policies, formularies, and utilization management criteria.
• Provide guidance and education to internal teams regarding authorization requirements and clinical best practices.

Payer & Stakeholder Collaboration

• Communicate directly with U.S. insurance companies, utilization management departments, and pharmacy benefit managers (PBMs).
• Facilitate peer-to-peer review coordination when required.
• Partner with operations, quality, and leadership teams to improve authorization workflows and turnaround times.

Quality & Compliance

• Maintain accurate records of utilization management activities in accordance with regulatory and audit requirements.
• Adhere to HIPAA, patient confidentiality standards, and ethical nursing practice.
• Participate in quality improvement initiatives related to authorization accuracy, denial reduction, and turnaround time.

Required Qualifications:

• Active United States Registered Nurse (RN) license in good standing (any compact or non-compact state).
• Minimum of 2 years of experience in prior authorization, utilization management, case management, or clinical review within a U.S. healthcare environment.
• Strong clinical background with solid understanding of disease processes, treatment pathways, and standards of care.
• Working knowledge of medical necessity criteria, payer policies, and utilization review processes.
• Proficiency in EHR systems, utilization management platforms, and prior authorization tools.
• Knowledge of CPT, ICD-10, HCPCS coding, and basic healthcare billing concepts.
• Strong written and verbal communication skills, with the ability to present clear clinical rationales.
• Ability to manage multiple cases simultaneously while meeting strict turnaround times.
• Analytical and detail-oriented, with sound clinical judgment and problem-solving skills.

Preferred Qualifications:

• Prior experience working with U.S. commercial payers, Medicare, or Medicaid plans.
• Experience supporting appeals, peer-to-peer reviews, or medical director escalations.
• Background in managed care, health plans, or payer-side utilization management.

Job Type: Full-time

Pay: Php35,000.00 - Php40,000.00 per month

Work Location: In person